The BASIS provides a forum for the free exchange of information related to addiction, and public access to the latest scientific developments and resources in the field. Our aim is to strengthen worldwide understanding of addiction and minimize its harmful effects. The Division on Addiction, Cambridge Health Alliance, a Harvard Medical School teaching hospital.

Thursday, November 16, 2017

Can vaping help smokers quit? The real story from a real story

Editor's Note: This op-ed comes from Dr. William G. Shadel, Associate Director, Population Health Program and Senior Behavioral Scientist at RAND Corporation.

A couple of years ago, my son’s coach approached me after practice and asked, “Can this thing really help me quit smoking?” He was holding a large, black box in his hand – a sort of stylized plastic straw jutted out from one side of the box and four green and red lighted buttons littered the other side. I recognized this as a “vape mod,” a more complicated and some would say, advanced version of the typical electronic cigarette or “vape pen.” In their modern form, electronic cigarettes were developed as an alternative nicotine delivery device in 2003 and were introduced in the United States a few years later. The devices quickly grew into a multimillion-dollar industry and some business analysts even suggested that the sale of electronic cigarettes would overtake regular cigarettes by 2021 (Craver, 2013). Rates of use certainly exploded in the last few years among both teens and adults (Jamal, Gentzke, Hu, Cullen, Apelberg, et al., 2017; Syamlal, Jamal, King, & Mazurek, 2016), and many countries, including the United States, are still trying to come to regulatory grips with the new technology.

The coach must have asked me because he knew I was involved in smoking cessation research. We had periodically discussed our professional lives, and at one too many practices I had hammered away on my computer, working on some new journal article or grant.

Correspondingly, I knew he smoked cigarettes. I’d see him sneak a puff here and there, behind a building or in his car before practice. I’ve never really been one to comment publicly on someone’s smoking habit or to offer advice unless asked, but I always appreciated him hiding his smoking from the kids. He was sensitive to the fact that he was a role model, and his standing as a coach meant he held sway over young people.

So what should I tell him? Would vaping help him quit smoking?

I knew the balance of research suggested vaping was safer than smoking cigarettes (Grana, Benowitz, & Glantz, 2014); even the harshest critics of electronic cigarettes have acknowledged as much. With an electronic cigarette, nicotine is heated and inhaled through a water-based vapor while nicotine in traditional cigarettes is carried on smoke generated by burning tobacco leaves that have been treated with numerous known and top-secret chemicals and flavoring agents. That difference alone certainly contributes to electronic cigarettes’ relatively lower levels of harm. I knew of estimates from econometric studies suggesting that the significant disease burden posed by smoking could be substantially reduced if cigarette smokers completely switched to a vaping product (Levy, Borland, Lindblom, Goniewicz, Meza, et al., 2017). There are likely some damaging respiratory (Chun, Moazed, Calfee, Matthay, & Gotts, 2017) and cardiovascular effects associated with vaping (Moheimani, Bhetraratana, Yin, Peters, Gornbein, et al., 2017), so relatively less harmful didn’t mean without harm. But at least I could tell him vaping was less harmful to him than his two-pack-a-day cigarette habit.

But what could I tell him about vaping or electronic cigarette use as a means to stop smoking cigarettes? Many smokers, at least early on, indicated they switched to vaping to reduce or quit smoking (Ayers, Leas, Allem, Benton, Dredze, et al., 2017). I knew about numerous case reports and uncontrolled studies where smokers indicated vaping helped them quit (see Hartmann-Boyce, McRobbie, Bullen, Begh, Stead, et al., 2016). Indeed, I was well aware of a loud and vigorous on-line community that believes strongly in the power of electronic cigarettes as a tool to quit smoking.

But what did the science tell me? What did data from the best kinds of studies, randomized clinical trials, show? Randomized trials assign smokers, by chance, to different treatment groups to compare whether those assigned to use electronic cigarettes stop smoking at higher (or the same or lower) rates than those assigned to some other treatment. The results of randomized trials are the basis of all clinical treatment recommendations across a range of problems, diseases, and disorders. Did science support the use of vaping as a tool to quit smoking?

The answer discouraged the coach: The evidence doesn’t support using electronic cigarettes to quit smoking (Hartmann-Boyce et al., 2016) and doing so could even lead to reduced chances of quitting (Kalkhoran & Glantz, 2016). I knew of ongoing randomized trials and that this conclusion was subject to change, but I could not, in good conscience, recommend electronic cigarettes as a way for him to quit smoking.

I told him that many good options were available and that these options had years of strong, accumulated scientific evidence to support their use. For example, over-the-counter nicotine replacement medicines (such as nicotine patches and nicotine gum) combined with specific types of counseling strategies (behavioral support, coping skills training) were effective at helping smokers to quit successfully (see Fiore et al., 2008). I suggested that he could speak to his doctor about prescriptions for other medicines (bupropion, varenicline) that are effective for helping smokers quit. I offered to send him web links to evidence-based on-line resources (https://smokefree.gov/; https://www.becomeanex.org/). I gave him the number for the toll-free smoking cessation quit line (1-800-QUIT-NOW); smokers who use quit lines have a better chance of quitting than those that do not (Stead, Hartmann-Boyce, Perera, & Lancaster, 2013).

He said I had raised “interesting points” and thanked me for my advice, but said he would probably continue to use electronic cigarettes to help him quit. He had already gone without cigarettes for a few days and said he felt pretty good. I congratulated him and wished him well. He is a terrific guy and had a very positive impact on my son. I wanted him to be successful and truly wished I could have offered him more, but the evidence on electronic cigarettes just didn’t guide me in that direction. Maybe it will someday, maybe sometime soon - but maybe not.

My son has since moved on to other pursuits, and we don’t see his coach regularly any more. I occasionally drive by the old practice spot and a few weeks ago happened to see him outside. I rolled down my window and waved hello. He waved back with his left hand while carefully hiding his right hand behind him. He smiled sheepishly and shrugged his shoulders. It was then that I noticed the faint cloud of smoke ringing his head. He was smoking a cigarette.

-- William G. Shadel, Ph.D.

What do you think? Please use the comment link below to provide feedback on this article.

Comments

Yes it can and it does. Vaping is probably the most successful quitting aid out there, especially when paired with the proper support. Far too many people in the anti-smoking lobby are letting perfect be the enemy of good enough.

Thank you for this posting, Bill. You are certainly grappling with tough questions where the evolution of evidence, and its application to practice, is subject to an array of interpretations.

I'm not sure, however, how to reconcile your characterization of the conclusions of the Cochrane Review ("The evidence doesn’t support using electronic cigarettes to quit smoking (Hartmann-Boyce et al., 2016)") with their actual conclusions:

"Authors' conclusions:
There is evidence from two trials that ECs help smokers to stop smoking in the long term compared with placebo ECs. However, the small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated 'low' by GRADE standards. The lack of difference between the effect of ECs compared with nicotine patches found in one trial is uncertain for similar reasons. None of the included studies (short- to mid-term, up to two years) detected serious adverse events considered possibly related to EC use. The most commonly reported adverse effects were irritation of the mouth and throat. The long-term safety of ECs is unknown. In this update, we found a further 15 ongoing RCTs which appear eligible for this review." (http://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose)

Certainly Cochrane's conclusions are guarded and qualified, but in my mind, they certainly lean towards recommending ecigs for smoking cessation.

And it is obviously not answerable, but I wonder how the coach might have pursued his quit attempt if you had provided him with this link from the UK National Health Service?

Disclosures:
My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication.

Thanks for commenting, Joe. I appreciate your careful attention to this post and time you took to engage with me. As you note, we're caught in an interesting and exciting time that could transform tobacco control as we know it. At the same time, the rapidly evolving state of the science makes it challenging to know what to do - both from practitioner and consumer perspectives. I'm pretty sure that all of us share the same goal of wanting to reduce the death and disease caused by tobacco smoking. And many of us have struggled for years with patients, friends, and family members who have tried many times to quit and ultimately not been successful. I believe that any new and innovative treatment deserves a fair chance to prove that it can help - and I hold no inherent bias one way or the other. If it works - great, let's deploy with great fanfare and minimal fuss.

My goal in this piece was to highlight the struggles that I face on a regular basis with what to recommend to people who ask for my advice on how to quit, and to offer concrete options for people who want to quit. I tend to be very conservative with my clinical recommendations, and am most comfortable with referring people to solid evidence-based recommendations (hence my suggestion that the coach at least consider treatment options that have a long, and rigorous science base to support them). My reading of the Cochrane review is less optimistic than your reading, largely because the quality of evidence so far is substandard and because more high quality studies are needed. I'd want to see see a larger body of evidence from high quality RCTs before I start recommending vaping as a way to quit. I thought my piece was very careful to acknowledge that vaping poses less harms than combustible cigarettes (this seems very clear) and that the evidence base was evolving and could change my recommendations if asked again.

My hope is that I'll be able to recommend a wider variety of options to anyone that asks in the near future - but I'll wait to see where the balance of evidence takes me before moving too far in any one direction. Is this too conservative an approach? Maybe - but I think the consequences are too great from recommending largely unproven (unproven because not enough high quality studies have been conducted to show positive effects) treatments too early. Thanks again!

Bill - I hope you'll indulge a few more thoughts from me as they hit me after reading your reply to my post.

First, I'm not sure I understand your point as to how our "readings" of Cochrane differ. I quoted the authors' conclusions, not an interpretation of their review. So is your point that their acknowledged uncertainty is so great, even though the available RCT-evidence points towards the products helping, that you just won't accept their conclusion?

Second, there are other supporting arguments of the potential utility of these products* for helping people quit.

*It is fair and important to acknowledge that the wide variety of products and liquids has an array of impacts--it offers lots of choices to consumers, but it also means that it is much tougher to generalize to "e-cigarettes" as one might to "nicotine gum".

Disclosures:
My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication.

I know that I'm a bit like a dog with a bone on this stuff, Bill, but with that confession stated, have you seen these two recent pieces in Addiction? I found the commentary provocative and the review paper essentially renders null and void the Kalkhoran & Glantz 2016 citation you used to support your "evidence is mixed" conclusion.

Do you agree? If not, why not? And if yes, would you consider changing anything in your initial post?

Disclosures:
My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication.

Thanks again for staying engaged with this piece, Joe. These articles make interesting points - I think the framework provided by Villanti et al. could be useful. My main point is that the balance of evidence from high quality RCTs does not (yet) support the use of vaping as a cessation tool - I'd like to see more than three RCTs and more data on longer term safety before making any recommendations to smokers that want to quit. It would also be nice to have some standardization of ingredients, delivery mechanics, and dosing with e-cigarettes or vaping devices before doing so. I realize that smokers say that they can and have quit smoking with these devices - anecdotal evidence and self-report correlational studies seem to support this assertion - but my evidence-based clinical recommendations remain as stated in the original essay. I don't think our RCT standards for evidence-based treatment - those that have been used for years and with other treatments for any number of disorders - should change for e-cigarettes.

I really hope to hope to reach a different conclusion in a year or two or three as the results of additional studies are published. But for the time being, I'll refer to the 2008 public health guidelines (Fiore et al., 2008).